Elsevier

Drug and Alcohol Dependence

Volume 152, 1 July 2015, Pages 109-115
Drug and Alcohol Dependence

Daily co-occurrence of alcohol use and high-risk sexual behavior among heterosexual, heavy drinking emergency department patients

https://doi.org/10.1016/j.drugalcdep.2015.04.011Get rights and content

Highlights

  • Explored daily co-occurrence between alcohol use and unprotected sex.

  • Alcohol use level was associated with increased odds of engaging in any sex.

  • Drinking was generally not associated with engaging in unprotected sex.

Abstract

Background

Global association and experimental studies suggest that alcohol use may increase sexual behavior that poses risk for exposure to sexually transmitted infections (STI) among heterosexual men and women. However, results from longitudinal and daily recall studies exploring the co-occurrence of alcohol use with various sexual risk outcomes in more naturalistic contexts have been mixed, and the bulk of this research has focused on college students.

Methods

The current study enrolled heavy-drinking emergency department (ED) patients and used a cross-sectional, 30-day Timeline Followback (TLFB) method to examine the daily co-occurrence between alcohol use and three sexual behavior outcomes: Any sex, unprotected intercourse (UI), and UI with casual partners (versus protected intercourse [PI] with casual partners, or UI/PI with steady partners).

Results

Results indicated that increasing levels of alcohol use on a given day increased the odds of engaging in any sexual activity and that heavy drinking (but not very heavy drinking) on a given day was associated with an increased odds of engaging in UI with either steady or casual partners. However, day-level alcohol use was not associated with an increased odds of UI with casual partners.

Conclusions

These findings suggest that alcohol may play an important role in increasing risk for HIV/STIs among heterosexuals, and support the continued need to target heavy drinking in sex risk reduction interventions. However, our results also suggest that alcohol may not universally result in unprotected sex with casual partners, a behavior posing perhaps the highest risk for HIV/STI transmission.

Introduction

Unsafe sex (i.e., unprotected sex that could lead to sexually transmitted infections [STI] and/or unintended pregnancies) is a significant cause of disease and disability (Glasier et al., 2006). Indeed, 6.2% of all disability-adjusted life years is attributable to unprotected sexual behavior in the United States (Ebrahim et al., 2005), and the annual direct medical costs associated with STIs topped $15.6 billion dollars in 2008 (Owusu-Edusei et al., 2013). The resurgence of previously well-controlled STIs (e.g., syphilis; Mattei et al., 2012) and growing treatment resistance (CDC, 2013) suggest that the STI-related burden may grow substantially in the near future, highlighting the importance of research into factors contributing to unsafe sex.

Alcohol use has been implicated as a key factor in the spread of STIs (Cook and Clark, 2005, Schneider et al., 2012), due in part to findings from cross-sectional (Grossman and Markowitz, 2005, Sen, 2002) and experimental findings (Rehm et al., 2012) supporting a relationship between alcohol use and unsafe sex. However, design limitations of these studies prevent conclusive inferences about the alcohol-unsafe sex link. Cross-sectional studies focusing on overall involvement in alcohol use and sexual risk (e.g., “over the past 6 months”) cannot establish the temporal proximity of the two behaviors. Moreover, experimental studies examine unprotected sex intentions using hypothetical scenarios. While there is evidence that intentions to use condoms are a robust predictor of condom use (Albarracin et al., 2001, Reinecke et al., 1996), important differences may exist between intentions rated in laboratory settings and real world behavior.

Situational association studies address these limitations by exploring whether alcohol use co-occurs with unsafe sex on the same occasion in naturalistic contexts. Early meta-analyses of event-level studies found that alcohol appeared to be unrelated to increased unsafe sex (Leigh, 2002, Weinhardt and Carey, 2000), but most of these studies explored their co-occurrence on just a few occasions (e.g., first sex, last sex). Studies utilizing more intensive assessments (e.g., cross-sectional daily recall or longitudinal designs) have the potential to explore whether alcohol and unsafe sex co-occur across many days, drinking occasions, and sex events over a given time period. Several such studies have been conducted since the aforementioned meta-analyses were published, and suggest that alcohol use consistently increases the likelihood of sex, but that the use of protection may depend on partner factors. For example, one daily diary study (Kiene et al., 2009) and two studies using situation and day-level recall assessments (Brown and Vanable, 2007, LaBrie et al., 2005) showed that drinking increased the odds of unprotected sex specifically with casual partners. However, at least one daily recall study found the opposite. Heavy drinking was associated with unprotected sex only with steady partners, and this relationship was significant only among women (Scott-Sheldon et al., 2010b). Moreover, one daily diary study found that alcohol use was not associated with condom use (Morrison et al., 2003). As such, while situational association studies are critical to understanding whether alcohol use increases unsafe sex in the real world, findings from these studies have been mixed. The vast majority of these studies have also focused on adolescents and college students. Although this may be warranted because of elevated STI risk among young adults (CDC, 2012), few studies have explored the alcohol-unsafe sex link in a broader range of adults or among those who drink heavily. Hence, findings from past studies on this link may be difficult to generalize beyond college students and young adults.

This study addresses this gap in the literature by examining the day-level co-occurrence between alcohol use level and sexual behavior in a sample of heavy-drinking emergency department patients who have engaged in some sexual risk behavior in the past 3 months (i.e., unprotected sex with a casual partner or unprotected sex with a steady partner who's fidelity is questioned or known). We used a cross-sectional daily assessment method (Timeline Followback; TLFB) to explore the association between alcohol use level and three key sex outcomes on a given day: The occurrence of (1) any sex, (2) unprotected intercourse (UI) with either steady or casual partners (versus protected intercourse [PI]), and (3) UI with a casual partner (versus “safer” forms of sex, such as PI with casual partners and/or UI/PI with a steady partner). These three variables allowed us to examine the association of alcohol use with engaging in any sex at all versus sex that is associated with increasing levels of risk. Given our study inclusion criteria, UI with any type of partner conveys some risk. However, because this outcome includes UI with steady partners, the risk for STI transmission may be lower for this outcome, since it may be more likely to involve risk reduction efforts other than condom use (e.g., sexual exclusivity, discussion of sexual history and STI status, use of alternative methods of contraception). UI with casual partners (versus PI with a casual partner or PI/UI with a steady partner), however, likely conveys the highest risk of the three. Based on past findings (e.g., Brown and Vanable, 2007, Kiene et al., 2009, LaBrie et al., 2005, Morrison et al., 2003), we hypothesized that higher levels of alcohol use, specifically use indicative of intoxication (i.e., consuming 5–11, or 12+ drinks on a given day for men, or 4–9, or 10+ drinks for women) would be uniquely associated with an increased odds of engaging in UI with casual partners versus engaging in “safer” forms of sex.

Section snippets

Materials and methods

This study used baseline data from 371 patients seeking medical treatment in the ED who enrolled in a randomized trial of a brief, combined intervention for alcohol and sex risk. This broader study explored whether a brief, motivational interviewing intervention could reduce heavy drinking and sexual risk behavior compared with brief advice. Inclusion criteria were: (1) Scores >8 for men and >6 for women on the Alcohol Use Disorders Identification Test (AUDIT; Babor et al., 2001) or >1 episode

Descriptive statistics

See Table 1 for demographics. Although the demographic characteristics of ED patients meeting criteria for “hazardous drinking” varies considerably across studies, fewer participants in our sample were married (likely due to our sexual risk eligibility criterion) but were otherwise similar to past studies conducted in EDs (e.g., Cherpitel, 1995, Neumann et al., 2004). TLFB data were entirely complete, with 0% of days missing. Thus, participants provided 9660 person-days of data across the

Discussion

This study is among the first to examine day-level relationships between alcohol use and sexual risk behaviors among heavy drinking, heterosexual emergency department patients. It is unique in its exploration of these associations in a more diverse sample with heavier drinking patterns than past studies. Using TLFB data, we examined whether alcohol use level on a given day was associated with engagement in sex, the use of protection during sex, and the type of partner (“casual” versus “steady”)

Role of funding source

This research was supported by NIAAA grant R01AA009892 and T32AA007459 to Peter M. Monti, and L30AA02336 to Tyler B. Wray.

Contributors

Tyler Wray conducted the analysis and interpretation of the data and prepared the manuscript.

Mark Celio assisted in the analysis and interpretation of the data and prepared preliminary versions of the methods section.

Christopher Kahler contributed to the conception and design of the study, assisted in data collection, assisted in the analysis of data, and revised drafts of the manuscript.

Nancy Barnett contributed to the conception and design of the study, assisted in data collection, and

Conflict of interest

The authors have no conflicts of interest to declare.

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